Medical Scribes Ease Pressure on Doctors and May Improve Patient Care

You describe symptoms to your doctor, who listens attentively and watches for nonverbal clues of pain or distress. He or she asks follow-up questions and maintains eye contact as you respond. Throughout the exam, the…

You describe symptoms to your doctor, who listens attentively and watches for nonverbal clues of pain or distress. He or she asks follow-up questions and maintains eye contact as you respond.

Throughout the exam, the physician remains fully focused, while relating clinical findings (“abdomen tender”) to the third person in the room — a scribe who quietly documents it all into a laptop.

There are no awkward pauses where your doctor clicks away on a keyboard or engages with a computer screen instead of communicating. As the patient, you feel seen and heard.

That doctor, in turn, feels less bogged down by documentation demands and spends less time catching up after hours. Instead, the doctor might leave a bit earlier, enjoy some family time and unwind.

Katie Hines of ScribeAmerica works as a scribe and quality assurance manager with Kootenai Health, based in Coeur d’Alene, Idaho. Her focus is the emergency department, outpatient clinic and urgent care.

A few years ago, Hines’ father, a physician assistant, introduced her to the job: “We have this new thing in our clinic and you’re a fast typist — you’d be great at it.”

However, the scribe role requires much more, Hines emphasizes. Scribes must have a handle on medical terminology and insurance documentation requirements, along with the skill to quickly sum up a patient’s health care visit using the proper format.

At ScribeAmerica, Hines says, trainees go through orientation to gain a foundation before working in a medical setting. For a family medicine practice, for instance, general classroom training would touch on common chronic diseases, such as hypertension and diabetes.

Scribes then have a supervisory period working alongside veteran scribes. The learning curve continues when scribes actually shadow health care providers — who might be physicians, nurse practitioners or physician assistants — in a fast-paced, often high-stress medical environment.

“We are elbow to elbow with the physicians,” Hines says, “We go into the room with the provider and are watching the interaction with the patient in real time. We are listening to their conversation, understanding that and then re-entering that into the (medical) notes as if we are the physician.”

Doctors are responsible for reviewing and signing off on all documentation. Scribes typically do not provide any direct patient care. Their presence is unobtrusive.

“I might ask a quick question when I think it’s appropriate,” Hines says. “But in general, we are very silent figures in the room. We really don’t want to infringe on the privacy of the patient and ultimately intrude on the conversation with the physician and the patient. Because our job is to remove the burden of dictation from the physician so that they can have that bedside time with the patient.”

The term scribe may sound medieval, evoking an image of someone taking notes with a quill pen. In reality, the medical scribe represents a somewhat revolutionary role, fueled in large part by the advent of the electronic medical record, or electronic health record.

EMRs were intended to streamline and standardize health care documentation throughout the health care system, while improving data gathering. For many physicians, however, computerized medical notes and order entry place added pressure and burden them with clerical tasks.

Increasing physician burnout has been at least partially blamed on EMRs. In addition, many patients express dissatisfaction when a doctor’s growing computer duties dominate medical visits.

Opportunity for Scribes

The health care environment was ripe for medical scribes to emerge. The role is still evolving, along with qualifications and training requirements. The minimum educational level is a high-school diploma or GED, although most scribes have at least some college education. In fact, many are prospective premed students.

Medical scribes are not licensed and there’s no mandatory certification. However, certification is available through organizations like the American College of Medical Scribe Specialists.

By 2020, there will be 100,000 medical scribes working in the U.S., according to a 2015 ACMSS estimate. The average base salary for a medical scribe is $28,570 per year, according to the Glassdoor website.

Documentation Fine-Tuning

Tammy Combs, a registered nurse and director of clinical documentation improvement at the American Health Information Management Association, says her group is seeing more scribes among health professionals they train.

Clinical documentation improvement includes being specific as possible when assigning patients a diagnosis, Combs says. When it comes to Medicare billing, for instance, “congestive heart failure” doesn’t carry the same diagnostic weight as “acute systolic congestive heart failure.” As scribes learn about document elements, they can clarify these issues with the health provider they’re assisting.

“Accuracy helps on many different levels,” Combs says. Precise documentation is important for addressing insurance issues such as receiving appropriate reimbursement and reducing denied claims. In addition, she says, a consistent, high level of detail improves the continuum of patient care as patients are seen by a variety of providers.

Timelier documentation is another advantage in using scribes, Combs says. “There’s a great opportunity out there for scribes and providers, for that scribe to take the burden off the providers and really improve patient care,” she says.

Scribe Results

Early research offers support for the provider-scribe partnership. A recent study, published online Sept. 17, 2018, in JAMA Internal Medicine, randomly assigned primary care providers either to work with scribes or go without in alternating three-month periods over one year.

Among providers, having medical scribes was associated with a decreased burden of electronic health record documentation and improved work efficiency. Among patients, about 60 percent reported that scribes had a positive bearing on their visits, in contrast to less than 3 percent of patients reporting a negative impact.

Another study involved an urban academic medical center that implemented a scribe program. Following implementation, doctors completing their emergency medicine residencies had improved perceptions of their medical education.

Among cardiologists in a single clinic, using scribes increased physician productivity and clinic revenues, according to a comparison study released Sept. 30, 2015, in the journal ClinicoEconomics and Outcomes Research.

In some medical facilities, designated staff members help relieve the documentation burden, but they aren’t necessarily scribes.

For the past seven years, Dr. Kevin Hopkins, a staff physician in the department of family medicine and medical director of Cleveland Clinic’s Strongsville Family Health Center, has been using medical assistants to help with documentation. “From the beginning, we noticed improvement in our patient satisfaction survey scores,” Hopkins says.

That arrangement falls under the “team documentation” model supported by the American Medical Association. It’s efficient because it involves personnel resources — in this case, medical assistants — who already would have a role in the practice. Now that role can expand.

After taking their patient to the exam room, medical assistants ask additional history questions and begin documentation. Next there’s a quick discussion with the physician outside the exam room.

“Then we go back in the exam room together,” Hopkins says. “The medical assistant sits at the computer, sort of in one corner of the exam room. I sit in a chair while the patient’s on the exam table, or vice versa. That allows me to have a direct line of sight and focus on the patient, and readily and easily turn to my medical assistant for eye contact, or making sure we’re understanding each other appropriately when it comes to the documentation.”

In the small exam rooms, physicians and medical assistants work in close proximity. Curtains offer patients privacy as needed. It’s uncommon for patients to say they’d prefer not to have a third party in the room. But once in a while, it happens, and the scribe may step out for a portion of the exam.

“Depending on what they bring up, I’ll educate the patient: Look, you can talk about that with them in the room. I understand it may be out of your comfort level, but these are medical professionals who hear these types of things all the time,” Hopkins says. Most patients become more accepting with repeat future visits.

High turnover is a major drawback with scribe arrangements. Having medical assistants committed to a practice can reduce that turnover, Hopkins says. “It’s incredibly beneficial to have another person in the room whom the patient sees as their advocate — another set of eyes and ears for accuracy.” Evaluation shows documentation quality is as good as or better than before, he adds: “For me, it’s a no-brainer that this is a far better practice model.”